Maternal, Infant And Young Child Nutrition (MIYCN) Policy . - Maharashtra

Maternal overweight and obesity are associated with maternal morbidity,preterm birth, and increased infant mortalityFetal growth restriction is associated with maternal short stature andunderweight and causes 12% of neonatal deaths and 20% of stunting inchildhood2.Under nutrition during pregnancy, affecting fetal growth, and the first 2 yearsof life is a major determinant of both stunting of linear growth and subsequentobesity and non-communicable diseases in adulthoodFurther, Pregnancy and breastfeeding can deplete the stores of vitamins andminerals in a mother’s body, particularly iron folate, which is vital to a baby’shealthy development in the womb. Healthy birth spacing reduces the chance thata baby will be premature or underweight. Waiting longer to conceive after a birthmeans a mother can give her new baby the best start in life; she will have moretime to care for her baby and for breastfeeding. It also gives parents time toprepare for the next pregnancy, including ensuring there are enough householdresources to cover the costs of food, clothing, housing and education.Strategies to improve Maternal, Infant and Young Child Nutrition (MIYCN) are akey component of the child survival and development programs in many countriesincluding India. The scientific rationale for this decision is clear, with steadilygrowing evidence underscoring the essential role of breastfeeding andcomplementary feeding as major factors in child survival, growth anddevelopment. The importance of breastfeeding as the preventiveintervention with potentially the single largest impact on reducing childmortality has been highlighted. Improvement of complementary feedinghas been shown to be the most effective in improving child growth, andthereby, together with maternal nutrition interventions, to contribute toreducing stunting3.As a global public health recommendation, infants should be exclusively breastfedfor the first six months of life (180 days) to achieve optimal growth, developmentand health. Thereafter, to meet their evolving nutritional needs, infants shouldreceive safe and nutritionally adequate complementary foods while breastfeedingcontinues for up to two years of age (2nd birthday) and beyond.4. In addition, agrowing body of evidence underscores the important global recommendation thatskin-to-skin contact be initiated in about 5 mins of birth in order thatbreastfeeding be initiated within the first hour of birth5. This skin-to-skin contactshould be continued uninterrupted till the time baby completes the firstbreastfeed.2 Source: Robert E Black at el and the Maternal and Child Nutrition Study Group. Maternal and child under nutrition and overweight in low-income andmiddle-income countries www.thelancet.com Published online June 6, 2013 http://dx.doi.org/10.1016/S0140-6736(13) 60937-X)3 Infant and young child feeding: programming guide. UNICEF, 20124 WHO/UNICEF Global strategy for infant and young child feeding, 20035 This recommendation is supported by evidence, is one of the Ten Steps to Successful Breastfeeding and is one of the core indicators for infant and youngchild feeding (2008 edition)

1.2 MIYCN in reducing Maternal morbidity &mortalityAdolescent girls are particularly vulnerable to malnutrition because they aregrowing faster than at any time after their first year of life. They need protein,iron, and other micronutrients to support the adolescent growth spurt and meetthe body's increased demand for iron during menstruation. Adolescents whobecome pregnant are at greater risk of various complications since they may notyet have finished growing. Pregnant adolescents who are underweight or stuntedare especially likely to experience obstructed labor and other obstetriccomplications. There is evidence that the bodies of the still-growing adolescentmother and her baby may compete for nutrients, raising the infant's risk of lowbirth weight and early death.Women are more likely to suffer from nutritional deficiencies than men are, forreasons including women's reproductive biology, low social status, poverty, andlack of education. Sociocultural traditions and disparities in household workpatterns can also increase women's chances of being malnourished. Many womenwho are underweight are also stunted, or below the median height for their age.Stunting is a known risk factor for obstetric complications such as obstructed laborand necessitates need for skilled intervention during delivery, to avoid injury ordeath for mothers and their newborns.Addressing women's malnutrition has a range of positive effects because healthywomen can fulfill their multiple roles — generating income, ensuring their families'nutrition, and having healthy children — more effectively and thereby helpadvance countries' socioeconomic development. Women are often responsible forproducing and preparing food for the household, so their knowledge — or lackthereof — about nutrition can affect the health and nutritional status of the entirefamily. Promoting greater gender equality, including increasing women's controlover resources and their ability to make decisions, is crucial. Improving women'snutrition can also help nations achieve three of the Millennium Development Goals- Goal 1: Eradicate extreme poverty and hunger, Goal 4: Reduce child mortality& Goal 5: Improve maternal health.1.3 MIYCN in reducing child morbidity andmortalityThe 2003 landmark Lancet Child Survival Series6 ranked the top 15 preventivechild survival interventions for their effectiveness in preventing under-fivemortality. Exclusive breastfeeding up to six months of age and breastfeeding upto 12 months (for the purpose of that study only) was ranked number one, withcomplementary feeding starting at six months at number three. These two6JonesG. et al. How many child deaths can we prevent this year? (Child Survival Series) The Lancet 2003 Vol. 362.

interventions alone were estimated to prevent almost one-fifth of under-fivemortality in developing countries.Across the globe, every year an estimated 13 million children are born withintrauterine growth restriction and about 20 million with low birth weight7. A childborn with low birth weight has a greater risk of morbidity and mortality and isalso more likely to develop noncommunicable diseases, such as diabetes andhypertension, later in life.The 2008 Lancet Nutrition Series8 also reinforced the significance of optimal IYCNon child survival. Optimal IYCN, especially exclusive breastfeeding, was estimatedto prevent potentially 1.4 million deaths every year among children under five(out of the approximately 10 million annual deaths). It has been proved thatearly initiation of breastfeeding within one hour contributes to 22% reduction inneo-natal mortality in Ghana. Neonatal and post neonatal deaths were found 5-6times lower in infants fed with colostrum.The impact is biggest in terms of reduction of morbidity and mortality fromdiarrhoea and pneumonia. Breastfeeding protects the effect on Haemophilus Bone of the causative agents for respiratory infections. Non breast fed childrenhave 250% higher risk of being hospitalised for pneumonia and asthma9. Breastmilk fed infants have reduced incidence of necrotizing enterocolitis, UTI, earinfections, asthma, meningitis and sepsis. Breastfeeding decreases chance ofdeveloping leukaemia10 and lymphoma11 by 30% in children.The evidence also points at several benefits of breast feeding for mothers such asless likely to develop Ovarian and Breast cancer, and lowers the risk of developingmaternal type II diabetes.1.4 MIYCN and Child GrowthOptimal MIYCN is essential for child growth. The period (First 1000 days) duringpregnancy and a child’s first two years of life is considered a “critical windowof opportunity” for prevention of growth faltering. Recent anthropometric datafrom low-income countries confirms that the levels of under-nutrition increasemarkedly from 3 to 18-24 months of age12.7United Nations Children’s Fund and World Health Organization, Low birthweight: country, regional and global estimates. New York, United NationsChildren’s Fund, 2004.8 Black R. et al. Maternal and child undernutrition: global and regional exposures and healthConsequences. (Maternal and Child Undernutrition Series 1). The Lancet 2008.9 Programing guide Infant & Young Child Feeding, UNICEF, June 201210Shu X-O, et al. Breastfeeding and the risk of childhood acute leukemia. J Natl Cancer Inst 1999; 91: 1765-7211An Exploratory Study of Environmental and Medical Factors of Potentially Related to Childhood Cancer. Medical & pediatric Oncology,1991; 19(2):1152112 Victora, C,. et al. Worldwide Timing of Growth Faltering: Revisiting Implications for Interventions. Pediatrics 2010; 125; e 473-e480.

After birth, a child’s ability to achieve the standards in growth is determined bythe maternal nutritional status as well as adequacy of dietary intake (whichdepends on infant and young child feeding and care practices and food security),as well as exposure to disease13. Under-nutrition and infection are interwined ina synergistic vicious cycle. Therefore, support to quality child feeding practices(breastfeeding, complementary feeding, feeding during illness and hygiene) andimprovement of household food security, together with disease prevention andcontrol programmes, are the most effective interventions that can significantlyreduce stunting and acute malnutrition during the first two years of life.Breastfeeding impacts growth in several ways, such as through reduction ofmorbidity due to infections, stronger immunological response to disease due totransfer of maternal antibodies and provision of the optimum balance of nutrients,growth factors, enzymes, hormones and other bioactive factors. For example,reviews of evidence on the effects on child health and growth of exclusivebreastfeeding for six months have presented lower morbidity fromgastrointestinal and allergic diseases, which in turn can prevent growth falteringdue to such illnesses14.Breast milk contains substances essential for optimaldevelopment of the infant’s brain, with effects on both cognitive and visualfunctions.Breastmilk alone is enough to meet all the nutritional needs of infants for the firstsix months of life. After six months of age, to meet all of a child’s nutritionalrequirements breastmilk needs to be complemented by other foods, although itcontinues to be an important source of nutrients as well as impacting diseasemorbidity and mortality15. At this age children have high nutritional needs forrapid growth, and appropriate complementary feeding provides key nutrients(e.g. iron and other micronutrients, essential fatty acids, protein, energy, etc.).Inadequate complementary feeding lacking in quality and quantity can restrictgrowth and jeopardize child survival and development.1.5 MIYCN and Child DevelopmentThe period from pregnancy to about 36 months (specifically the first 1000 days –the critical window of opportunity) is a critical period in early childhooddevelopment for stimulating positive cognitive development, particularly insettings where ill health and under nutrition are common16. Mother’s optimalnutrition is the core for promoting optimal early childhood stimulation.Furthermore, a Lancet series on Child Development17 recognized tackling stuntingScrimshaw NS et al. Interactions of nutrition and infection. Geneva: World Health Organization. 1968.Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Advances in Experimental Medicine and Biology 2004:554:63-77.15 Jones G. et al. How many child deaths can we prevent this year? (Child Survival Series) The Lancet 2003 Vol. 362.16 Sternberg RJ. Intelligence and lifelong learning: what's new and how can we use it? Am Psychology 1997 Oct; 52(10):1134-9.17 Engle P et al. Strategies to avoid the loss of developmental potential in more than 200 million Children in the developing world. The Lancet 2007: 369.1314

and iron deficiency as two of the four most effective early childhood developmentinterventions, along with addressing iodine deficiency and cognitive stimulation.In addition, breastfeeding and responsive feeding provide constant positiveinteractions between mother and child which can contribute to emotional andpsychological development of infants. There is also strong evidence of higherperformance in intelligence tests among those subjects who had been breastfedas infants18.1.6 MIYCN and Children with Severe AcuteMalnutrition (SAM)Malnutrition has a negative impact on cognitive development, school performanceand productivity. Stunting and iodine and iron deficiencies, combined withinadequate cognitive stimulation, are leading risk factors contributing to thefailure of an estimated 200 million children to attain their full developmentpotential. Each 1% increase in adult height is associated with a 4% increase inagricultural wages19 and eliminating anaemia would lead to an increase of 5% to17% in adult productivity. Malnutrition is an impediment to the progress towardsachieving Millennium Development Goals 1 (Eradicate extreme poverty andhunger), 2 (Achieve universal primary education), 3 (Promote gender equalityand empower women), 4 (Reduce child mortality), 5 (Improve maternal health)and 6 (Combat HIV/AIDS, malaria and other diseases)20.Children with SAM are nine times at risk of death. It is recommended that anytraining on management of SAM (facility-based or Community basedmanagement of acute malnutrition (CMAM)-(Village Child Development Centresin Maharashtra) including during an emergency should include a module on MIYCNcounselling21. MIYCN and CMAM should be conceptualized and planned as twointegral parts of a single programme to prevent and treat under nutrition, not astwo completely separate programmes. The design, planning, training, communitymobilization, health and ICDS worker activities and supervision structures shouldaddress both CMAM and MIYCN in one single package. Empowering mothers andcare givers on MIYCN would contribute significantly in preventing the child fromsevere acute malnutrition.Before discharge of children admitted with SAM, review of feeding practices of themalnourished children should be done. Counselling on exclusive breastfeeding or18Horta, B et al. Evidence on the long-term effects of breastfeeding: systematic review and Meta-analyses. WHO 2007.19Haddad L, Bouis HE. The impact of nutritional status on agricultural productivity: wage evidence from the Philippines. Warwick (United Kingdom ofGreat Britain and Northern Ireland), Development Economics Research Centre. Papers, No. 97, 1989.20Annex 2, Comprehensive implementation plan on maternal, infant and young child nutrition endorsed by 65th World Health Assembly,Geneva, May 2012.21 The UNICEF Community MIYCN Counselling Package can be used; it contains sessions tailored to the context of SAM.

continued breastfeeding and timely, safe, appropriate and adequatecomplementary feeding (after 6 months of age) should be done. This shouldinclude demonstration of food preparation and sharing of recipes with mothers foroptimal use of locally available foods for children 6-23 months.1.7 HIV and Infant FeedingHIV infection has both a direct impact on the nutritional status of women andchildren who are infected and an indirect effect through alterations in householdfood security and inappropriate choices of infant-feeding practices in order toprevent mother-to-child transmission of HIV. Poor food security also increasesrisk-taking behaviour by women that places them at increased risk of becominginfected with HIV.For all infants born to HIV-infected women, breastfeeding is stronglyrecommended as the feeding option of choice. This holds true irrespective ofwhether the mother is receiving ART, ARV prophylaxis during pregnancy andlactation, or neither. In view of emerging evidence, extended anti-retroviral (ARV)prophylaxis to infant and/ or mother should be considered for preventingpostnatal transmission of HIV.With provision of anti-retroviral interventions, breastfeeding is madedramatically safer and the “balance of risks” between breastfeeding andreplacement feeding is fundamentally changed. The mother’s own health is alsoprotected.1.8 MIYCN and breast feeding mothers at workplacesEmployment modifies breastfeeding behaviour of a woman in significant mannerwith full time employment having the most detrimental impact. In a study byMandal and his co-workers it has been established that, in comparision with nonworking mothers, the probability of breastfeeding cessation among full timeworkers was four times as higher for women availing maternity leave of less than6 weeks while it was half for women with less than 12 weeks of leave.22In Urban areas many families need and use Child CareServices (DayCare/Creche) while in ruarl areas infants are carried to work by mothers or areleft at home with care takers many a times they being the older sibling at home.In the Scholars Research Library from the Annals of Biological research, 2011, itis mentioned that during the first six months of life, children who develop the best22Infant & Young Child Feeding Behaviours among working mothers in India: Implications for Global healthPolicy and Practice by Dr. Vinay Kumar et. al; International Journal of MCH & AIDS (2015), Vol 3, Issue 1, Pg 715

are those who have a tremendous amount of attention, and who enjoy a lot offun play. When the children begin crawling at six or seven months of age, theyneed access to someone who is excited to teach them. This process helps tosupport their curiosity, increase their enthusiasm, and help their overalldevelopment. It is very rare for a caregiver to show the same amount of interestin a child that a parent would. This is because mothers are very quick to respondto a baby’s non-stop demands for love and attention.In Maharashtra there are higher number of women working in unorganized sectorlike in fields, construction sites, brick kilns etc as daily wage labourer than thewomen working in organized corporate sector. The maternity benefits areavailable to mothers working in the organized sector but is missing completely inthe unorganized sector. This policy guidelines will help support breast feeding andnursing of children to the working mothers in the organized as well as unorganizedsectors .1.9 MIYCN in emergencies –Natural and manmade disastersInfants and young children are among the most vulnerable groups inemergencies. Interruption of breastfeeding and inappropriate complementaryfeeding increase the risks of malnutrition, illness and mortality. The MIYCNstrategies need to specifically address MIYCN programming in emergencies23 forthe following reasons:Maternal nutrition during emergencies is compromised which in turn affects thefetal nutrition. During emergencies/disasters and epidemics pregnant andlactating mothers are prone to malnutrition & infections. Hence pregnant womenand lactating mothers should be given food supplements/food grains with priorityalong with recommended micronutrient supplements and should receive medicalcheck ups at frequent intervals.The best food for all infants in exceptionally difficult circumstances andemergencies is their own mother’s milk unless medically contraindicated.Breastfeeding is safe, free and a crucial life-saving intervention for vulnerablechildren whose risks of death increase markedly in emergencies. Emergencysituations exacerbate risks for non-breastfed children and those who are on mixedfeeding. Both exclusive breastfeeding up to 6 months and continued breastfeedingafter 6 months are crucial in reducing the risk of diarrhoea and other illnesses inolder children, which is heightened in emergencies.23Infant and young child feeding: programming guide. UNICEF, 2012

Donations of breast milk substitutes undermine breastfeeding and cause illnessand death. Safe, adequate, and appropriate complementary feeding, whichsignificantly contributes to prevention of under nutrition and mortality in childrenafter 6 months, is often jeopardized during emergencies and needs particularattention. MIYCN is central to reducing the high risk of undernutrition duringemergencies.1.10 Current Status of MIYCN in MaharashtraMaharashtra has ma

2.3 Feeding the infant/young child under "normal" circumstances 18 2.4 Feeding the Infant/Young Child of a working mother at work places 20 2.5 Feeding the Infant/ Young Child who is exposed to HIV 22 2.6 Feeding Infant and Young Child in Other Specific Situations 23 Chapter 3 : Implementation Strategy 3.1 Implementation framework 28